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Transabdominal Preperitoneal
(TAPP) Repair
VamsiV.Alli andEricM.Pauli
8
Abbreviations
MPO Myopectineal orice
rTAPP Robotic transabdominal preperitoneal
TAPP Transabdominal preperitoneal
TAR Transversus abdominis release
TEP Total extraperitoneal
Introduction
Minimally invasive approaches to hernias of the
myopectineal orice (MPO) of Fruchaud build
upon historic posterior approaches to the preperitoneal space such as those of Nyhus and Read [1]
as well as Rives, Stoppa, Wantz, and Rignault’s
addition of widely overlapping mesh, resulting in
the so-called giant prosthetic reinforcement of
the visceral sac [2]. Both the retromuscular (pretransversalis) plane and the preperitoneal plane
can be entered to accomplish a minimally inva-
Electronic Supplementary Material The online version
of this chapter (doi:10.1007/978-3-319-92892-0_8)
contains supplementary material, which is available to
authorized users.
V. V. Alli · E. M. Pauli (*)
Division of Minimally Invasive and Bariatric Surgery,
Department of Surgery, Penn State Hershey Medical
Center, Hershey, PA, USA
e-mail: valli@pennstatehealth.psu.edu;
epauli@pennstatehealth.psu.edu
sive repair of an MPO hernia. In the case of a
total extraperitoneal (TEP) repair (see Chap. 9),
the desired plane is accessed directly, generally
in the periumbilical region, thus avoiding any
violation of the peritoneal cavity. Conversely, in a
TAPP repair, the peritoneal cavity is accessed to
visualize the MPO bilaterally. Laparoscopic
instrumentation is then used to develop the
desired plane (generally the preperitoneal plane)
to afford repair.
Understanding the difference between the pretransversalis/retromuscular and the preperitoneal
planes, learning to correctly dissect one or the
other, and developing the skill to comfortability
(and knowingly) transition between the two are
critical for any surgeon attempting to master minimally invasive inguinal hernia surgery. Similarly,
posterior approaches to abdominal wall hernias,
particularly the transversus abdominis release
(TAR) method of component separation, rely on
understanding the difference between the retromuscular and preperitoneal planes [3]. As such,
familiarity with the anatomy of a TAPP repair will
facilitate performance of both open and minimally
invasive TAR herniorrhaphy (and vice versa).
Laparoscopic TAPP repairs are also the foundation upon which robotic surgical repairs of
MPO hernias (so-called rTAPP repairs) are
founded. Because of the recent and quite rapid
rise in the adoption of robotic techniques, an
understanding of laparoscopic TAPP methods is
critical for any surgeon seeking to perform the
© Springer International Publishing AG, part of Springer Nature 2018
M. P. LaPinska, J. A. Blatnik (eds.), Surgical Principles in Inguinal Hernia Repair,
https://doi.org/10.1007/978-3-319-92892-0_8
55
56
Umbilical por
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V. V. Alli and E. M. Pauli
operation with robotic assistance. Please see
Chap. 10 for further details on rTAPP.
There are innumerable manuscripts comparing TAPP and TEP methodology and expounding
upon the virtues of each. Such comparisons are
more thoroughly reviewed elsewhere in this
book. In this “technique” chapter, we would like
to highlight two technical advantages offered by
the TAPP approach. First is the ability to view the
entire lower abdomen prior to performing any
dissection over the MPO. This affords the surgeon the ability to accurately inspect both MPOs
for evidence of hernias in the direct, indirect,
and/or femoral spaces. This is particularly useful
in the cases with a clear unilateral hernia diagnosis but an unclear contralateral one. Secondly, in
cases of incarcerated hernias, the abdominal
access afforded by the TAPP approach is useful
not only to facilitate manual reduction of incarcerated contents but also for inspection and
resection (if necessary) of the recently freed
viscera.
The primary technical disadvantage of the
TAPP approach is that the need to enter the
abdominal cavity requires the ability to navigate
and safely manage intra-abdominal adhesions
(Fig.8.1). Patients with prior extensive intraperitoneal surgery or signicant risk of adhesions
below the level of the umbilicus are not ideal candidates for a TAPP repair. In these instances a
TEP or an open anterior approach should be
considered.
t
Adhesed
Bowel
Fig. 8.1 Intra-abdominal adhesions encountered during
TAPP repair. Bowel (indicated by arrows) adherent to the
anterior abdominal wall as a result of prior midline
laparotomy
Operative Technique
Anesthesia
Laparoscopic TAPP hernia repairs typically
require general anesthesia and neuromuscular
blockade. We routinely inltrate local anesthetic
at port site locations to minimize postoperative
pain and reduce early narcotic requirements. We
utilize a low-volume intravenous uid protocol to
avoid signicant distention of the urinary bladder
during the course of the operation. Following
best practice guidelines [4], all patients receive
prophylactic antibiotics immediately prior to surgical incision (although recent literature suggests
that the administration of antibiotics for inguinal
hernia repair is not only unnecessary but potentially detrimental [5]).
Patient Preparation andPositioning
The patient is instructed to void immediately
before transportation to the operative theater.
Upon arrival to the room, they receive prophylactic subcutaneous anticoagulation (5000 units of
unfractionated heparin) and serial compression
devices to reduce the risk of venous thromboembolism. Following induction of anesthesia, the
patient is positioned in a supine position on the
operative table with both arms tucked. This positioning permits both surgeon and assistant to comfortably stand toward the head of the bed (generally
at the level of the patients shoulder) without leaning backward over outstretched arm boards.
Because steep head-down positioning is utilized
during the case, the patient must be secured to the
bed in a reliable and robust fashion. We preferentially eschew the use of a Foley catheter unless
there is a reasonable expectation that bladder distention will interrupt the progress of the case (e.g.,
anticipated difcult bilateral dissection leading to
a lengthy operation, prior mesh in situ, active
symptoms of bladder outlet obstruction most typically from benign prostatic issues, or patients who
perform self-catheterization at home).
The hair on the abdomen and groin are
clipped, and a chlorhexidine-based preparation
ab
8 Transabdominal Preperitoneal (TAPP) Repair
57
is used to cleanse the skin. Preparation should
take into consideration the need for management of both intra-abdominal complications as
well as the need to convert to an open approach.
We typically prep from the xyphoid to the upper
thigh but generally do not include the genitals in
the prep unless there are some additional mitigating circumstances (such as an incarcerated
hernia that may require external counterpressure
to free).
A single laparoscopic tower (including light
source, video processor, insufator, electrosurgical generator, and video monitor) is placed at the
foot of the bed (Fig. 8.2a). Alternatively, the
tower can be positioned off the patient’s head
(generally to the patient’s left, opposite the anesthesia machine) with a secondary monitor placed
at the foot of the bed (Fig. 8.2b). The assistant
stands ipsilateral to the side of interest and is
responsible for camera navigation. The surgeon
stands contralateral to the hernia with a monopolar cautery foot pedal positioned for easy access
during the procedure.
Port Placement
For TAPP hernia repairs, we prefer to make initial entry using a 12mm Hasson cannula utilizing a curvilinear incision above the umbilicus,
although other entry methods may be used based
on surgeon’s comfort and experience. The larger
umbilical port provides a great deal of versatility for this operation including the easy introduction of large pieces of mesh to complete the
repair. An open access method also permits
repair of any umbilical hernia defects which are
often found in conjunction with inguinal hernias
[6]. A 5mm, 30° laparoscope is utilized to allow
maximal exibility in operative visualization.
Pneumoperitoneum is established using a carbon dioxide (CO2) insufator set to 15mm of
mercury (mmHg) pressure; the patient is placed
in a steep head down (Trendelenburg) position
to allow gravity-based retraction of the viscera
away from the MPO. Visual inspection of the
MPO is then undertaken to conrm the
diagnosis.
Anesthesia
machine
Surgeon
Anesthesia
machine
SurgeonAssistant Assistant
Lap tower
Foot pedal Foot pedal
H
Lap tower
Fig. 8.2 Room setup for laparoscopic TAPP repair of a
left inguinal hernia. (a) Standard setup utilizes a
laparoscopic tower positioned at the foot of the table.
(b) Alternative setup places a secondary monitor at the
foot of the table, with the laparoscopic tower positioned at
the head of the bed
H
Secondary
monitor
58
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V. V. Alli and E. M. Pauli
Two additional 5 mm ports are placed laterally, their location varying slightly based on the
visual inspection of the MPO.For patients undergoing bilateral repairs, ports are placed symmetrically: each several centimeters lateral to the
linea semilunaris (lateral border of the rectus
muscle) and each just superior to the level of the
umbilical port (Fig.8.3). For patients undergoing
a unilateral repair, the ports are shifted slightly to
improve the ergonomics of a unilateral operation.
The 5 mm port contralateral to the side of the
defect is shifted toward the side of the hernia,
occupying a position now just lateral to the linea
semilunaris. The 5mm port ipsilateral to the hernia is shifted slightly more cephalad, occupying a
position more superior to the umbilical port but
still lateral to the linea semilunaris. Figure8.4a
and b illustrate port placement for unilateral right
and left repairs, respectively.
5
Fig. 8.3 Port placement diagram for bilateral TAPP
inguinal repair
12
5
HH
Utilizing smaller (5 mm), non-cutting (radially dilating) trocars and avoiding port placement
through the linea semilunaris are all maneuvers
intended to reduce the risk of postoperative port
site hernia formation.
Ergonomic andOperative Flow
Considerations
One of the common criticisms of TAPP repair is
that port placement is non-ergonomic and
requires the surgeon to lean across the table to
perform the operation. This position results from
the use of the two lateral ports as the working
ports and the umbilical port for the camera (generally a 10 mm lens assembly). The operating
surgeon fatigues quickly and can develop back
pain from leaning across the table, while collisions with the assistant’s camera arm slow the
repair and result in an unsteady view of the operative eld (Fig.8.5a and Video 8.1 illustrate these
issues associated with this port utilization
scheme).
The use of a high-denition 5mm, 30° laparoscope and shifting its position to the 5mm port
ipsilateral to the hernia entirely eliminate these
ergonomic concerns. The high-denition camera
and 30° lens allow the assistant to provide a view
of the operative eld virtually identical to that
obtained by the use of a 10 mm laparoscope
placed centrally. However, shifting the camera
laterally permits the surgeon to operate through
the umbilical and contralateral 5 mm port (the
two ports closest to the surgeon) while maintaining an upright and ergonomically correct position
(Fig. 8.5b and Video 8.1 illustrate more ergonomic port utilization).
We preferentially utilize instruments passed
through the midline umbilical port as the primary
dissection tools. Only instruments passed through
the midline are attached to the monopolar cautery
cable. Instruments passed through the 5mm port
contralateral to the hernia generally serve
retraction and counter traction purposes. This
system of port utilization means that when two
similar instruments are present in the operative
eld (e.g., two Maryland dissectors), there is no
ab
8 Transabdominal Preperitoneal (TAPP) Repair
59
H
Fig. 8.4 Diagram of port placement for unilateral right (a) and left (b) TAPP inguinal hernia repair
H
confusion about where energy is going to be
Procedure Steps
delivered. Since the retraction hand is often out
of the eld of view of the camera and often
retracts downward toward the bowel, this convention also reduces the risk of inadvertent thermal injury to the bowel.
To improve the ow of the case, we have
available both a laparoscopic scissors and a
Maryland dissector with cautery attachments.
Switching between these two primary dissection
devices therefore requires no more than instrument withdrawal and a simple switch of the
monopolar cord from one to the other. Tool
change does not require the removal and replacement of instrument handles. Many standard laparoscopic instrument trays include only one handle
capable of attachment to a monopolar cautery
cable, so an extra handle may need to be added to
the TAPP instrument set.
Video 8.2 demonstrates all of the operative steps
of a bilateral TAPP repair as detailed below. By
convention, the umbilical port is the primary
working port used for dissection, and the only
port through which electrosurgical devices are
placed. The contralateral 5mm port is utilized for
retraction of the peritoneal ap and hernia sac
during the dissection. There are, however, occasions where the opposite conguration is utilized
for retraction, most notably during reduction of a
large indirect sac and/or large lipoma of the cord.
After port placement, peritoneoscopy is performed to assess for trocar site or access injuries
and to conrm the diagnosis of hernia/herniae.
Atraumatic graspers can be used to reduce any
incarcerated contents and to manually reposition
any adjacent bowel that did not clear the MPO
60
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V. V. Alli and E. M. Pauli
Fig. 8.5 Ergonomic
considerations of port
utilization. (a) Surgeon
must lean over the
patient and collides with
the assistants arm when
the umbilical port is
utilized for the
laparoscopic camera/
lens assembly. (b)
Placing the camera/lens
assembly ipsilateral to
the hernia allows upright
posture for both surgeon
and assistant
a
b
with Trendelenburg positioning. Adhesions in the
region of the MPO should be taken down sharply
with minimal use of surgical energy. The goals of
adhesiolysis are to free any points of tension that
may tear or preclude easy ap closure and to
move bowel away from the anticipated location
of preperitoneal dissection. Care must be taken to
avoid injury not only to the viscera but also to the
peritoneum which should ideally be intact or
readily closed at the conclusion of the preperitoneal dissection.
Peritoneal Flap Creation
We typically create a very large peritoneal ap,
beginning the dissection well above the hernia
defect. Preperitoneal access begins just below the
umbilicus and just lateral to the medial umbilical
ligament. When bilateral repairs are performed,
the peritoneum is left uncut and undissected from
medial umbilical ligament to medial umbilical
ligament to permit easier ap alignment and closure at the end of the procedure.
From this medial starting position, endoscopic
sheers and monopolar coagulation current are
utilized to create a peritoneal incision directed
straight lateral (not inferior-lateral) from the
starting point. This requires upward torque on the
scissors from the midline port that results in the
instrument tips being aimed for a point just below
the 5mm port on the side ipsilateral to the defect.
Care is taken to remain in the true preperitoneal
plane (posterior or deep to the transversalis
fascia) as this is an avascular plane and minimal
(if any) energy is required for dissection. The
transversalis fascia should remain in apposition
to the rectus muscle. Exposed muscle bers are
an indication that dissection has extended into the
wrong plane (Fig.8.6). Care must also be taken
to avoid inadvertent injury to the inferior epigastric vessels which run between the transversalis
8 Transabdominal Preperitoneal (TAPP) Repair
61
Transversalis
Rectus muscle
Transversalis fascia
Peritoneal flap
Fig. 8.6 TAPP dissection should occur between the peri-
toneum and the transversalis fascia. Identication of bare
muscle bers indicates incorrect entry in the pre-transversalis plane
Epigastric vessels
Transversalis
Fusion plane
Fig. 8.8 Fusion plan between peritoneum and transversa-
lis that occurs near the linea semilunaris
whether their off-screen counter-tension is appropriate (facilitating dissection) or inappropriate
(resulting in tears in the thin peritoneal ap or
ineffectual/inefcient dissection).
In virtually all patients, there is a fusion plane
between the peritoneum and transversalis fascia
that occurs at the lateral 1/3 of the rectus muscle
near the linea semilunaris (Fig.8.8). This plane
runs in a cranio-caudal direction along the length
of the rectus muscle. Identication of this fusion
is important for several reasons:
Peritoneal flap
Fig. 8.7 The inferior epigastric vessels are visible
through the intact transversalis fascia
fascia and the rectus muscle itself. While not
directly visualized during this part of the dissection, the epigastric vessels are clearly identiable
through the intact transversalis fascia (Fig.8.7).
Throughout the dissection, rm posterior and
cephalad traction of the ap is critical for separation of the peritoneum and transversalis fascia.
This pull should also be directed medial (during
lateral dissection) or lateral (during medial dissection) to facilitation ap creation. One of the
hardest elements of a TAPP repair to learn/teach
is the required force and tension vector for retraction. The surgeon must learn from on-screen
visual cues and from subtle haptic feedback
1. Due to the fusion, there is a tendency to inad-
vertently enter the pre-transversalis plane or
to tear holes in the peritoneum. Correct dis-
section may require sharp dissection using
scissors or cautery, in addition to altering the
traction/countertraction maneuvers to safely
release the peritoneum.
2. The fusion generally happens within 1 cm
(medial/lateral) of the location of the epigas-
tric vessels. Finding the fused segment should
therefore alert the surgeon to their proximity
to the vessels.
3. The remainder of the operative dissection can
be divided into three distinct zones of
dissection relative to the fused section of the
peritoneal ap (representing the location of
the epigastric vessels). We describe these as
the medial, lateral, and middle zones of the
peritoneal ap.
62
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Medial Dissection
V. V. Alli and E. M. Pauli
Medial dissection will open the space of Retzius
and permit identication of the pubic symphysis
in the midline, followed by identication of
Cooper’s ligament. For bilateral repairs, dissection can be continued across the midline at this
point due to the ease with which the space of
Retzius opens. The most efcacious maneuver
here is a posterior/medial push directed downward toward the bladder. When direct defects are
present, they can often be reduced with a simple
downward push from the Maryland dissector
entering from the midline port. For larger direct
defects, a two-handed maneuver is often required.
Here, the midline Maryland grasper is used to
grab the “pseudosac” (the bulging transversalis
fascia), and the Maryland retractor is moved into
the dissection plane to push downward on the
peritoneum. By working hand over hand in this
fashion, the peritoneum over the direct defect can
be easily reduced (generally much easier than
indirect sac reduction). The plane should be
opened inferior enough to permit identication of
the inferior pubic ramus (and the obturator space)
as well as the retropubic space in the midline.
Because the fused middle part of the dissection has not been completed, medial dissection is
facilitated by navigating the laparoscope into a
position between the fused peritoneum/transversalis fascia (laterally) and the medial umbilical
ligament (medially) and utilizing the 30° lens to
look directly inferiorly, toward the bony pelvis.
This maneuver requires a camera operator capable of navigating into the preperitoneal plane,
past undissected parts of the ap and around
working instruments without dirtying the lens or
colliding with working instruments.
During medial dissection, several critical
structures should be identied. As mentioned
above, the urinary bladder is left in continuity
with the peritoneal ap as the dissection
approaches (and ultimately crosses) the midline.
Early medial dissection (including contralateral
medial dissection in patients undergoing bilateral
repairs) may help avoid injury to the bladder if no
Foley catheter is used as the bladder will increasingly distend with urine as the case progresses
Cooper’s
ligament
Corona mortis
Fig. 8.9 Corona mortis vessels along the pubis. Also vis-
ible is Cooper’s ligament superior to the bone
even when a low volume resuscitation strategy in
employed. The lateralmost aspect of the medial
dissection is the femoral and obturator spaces,
and care must clearly be taken to avoid the neurovascular structures found here.
Running to/from the iliac vessels are small
vascular branches that supply the bony pelvis (the
so-called corona mortis vessels). These branches
are often encountered running along the pubic
rami toward the symphysis (Fig.8.9). They need
to be avoided during dissection and their position
noted so that they are not injured during mesh
placement and/or xation. Small amounts of
bleeding from these vessels can result in the
development of a large postoperative hematoma
because of the ease with which the space of
Retzius opens. This is particularly critical in
patients requiring anticoagulation or antiplatelet
agents for medical comorbidities or in whom nonsteroidal anti-inammatory agents that alter platelet function (such as ketorolac) will be given.
Lateral Dissection
During the lateral dissection, the primary goals
are to identify and preserve the neurovascular
structures of the lateral abdominal sidewall while
identifying the lateral aspect of any indirect hernia sac. Both of these goals are most easily
accomplished by ensuring that dissection leaves
8 Transabdominal Preperitoneal (TAPP) Repair
Preperitoneal fat
(ceiling)
“Bare” peritoneum
(floor)
Fig. 8.10 The “oor” of dissection should be bare perito-
neum; all preperitoneal fat has been lifted up to the
“ceiling,” leaving all critical structures against the pelvic
sidewall
all preperitoneal fat against the abdominal and
pelvic sidewall (i.e., on the “ceiling” of dissection) and that only the peritoneum is being
retracted medially (i.e., the “oor” of the dissection is bare peritoneum) (Fig.8.10). The lateral
dissection should be undertaken with care to
avoid damage to the lateral femoral cutaneous,
anterior femoral cutaneous, femoral branch of
genitofemoral, and femoral nerves within the socalled triangle of pain. This zone is bounded by
gonadal vessels medially, ileopubic tract superiorly, and the peritoneal reection laterally.
If at any point the surgeon questions the direction or extent of the lateral dissection, the camera
can be backed away from the dissection and out of
the preperitoneal space. The retraction hand is
used to raise the peritoneal ap back to its native
position. This gives a clear overview of the entire
dissection ap and is one of the advantages offered
by TAPP repair. At some point in the lateral dissection, further inferior and lateral dissection is hindered by the fusion plane in the middle zone,
prohibiting adequate counter traction. At this point
it is time to perform the middle dissection.
Middle Dissection andSac Reduction
Working carefully under the epigastric vessels, the
middle of the ap can be created. Blunt and sharp
63
dissection are utilized along with judicious electrocautery to separate the peritoneum from the
transversalis fascia by following the fusion plane
between the two inferiorly. Once the medial edge
of the hernia sac has been identied, the counter
traction hand can be shifted into the preperitoneal
plane and used to grasp the proximal hernia sac.
The sac is separated from the cord structures by
working on the lateral edge and pulling the sac out
of the indirect defect. Complete sac reduction can
be achieved in almost all cases. Occasionally a
longer sac poses a difcult dissection and may be
more safely divided with cautery. As the sac is
being reduced, the nal portion of the dissection
separates the inferior sac wall from the retroperitoneal structures. It is at this point that the vas deferens is encountered. The sac is separated from the
vas and the dissection continued taking the peritoneum off of the retroperitoneal structures beyond
the area where the vas deferens crosses medially
over the iliac vessels. Dissection in the so-called
triangle of doom completes the circumferential
mobilization of the indirect sac from the cord
structures and creates room for inferior overlap of
the mesh. Despite the proximity to the iliac vessels, it is critical to be thorough in completing the
inferior dissection as the inferior location is the
most common site of hernia recurrence following
laparoscopic inguinal herniorrhaphy.
Cord Lipoma Management
The cord should be inspected for any retroperitoneal fat that accompanied the hernia sac (the socalled lipoma of the cord) (Fig. 8.11a). Any
lipomas encountered should be reduced to eliminate symptoms related to the bulging fat and to
avoid symptoms (pain and a bulge) that may
mimic a hernia recurrence. The blood supply of
these lipomas runs adjacent to the cord along the
pelvic sidewall in the retroperitoneum. They can
generally be reduced back beyond the area where
the inferior edge of the mesh will be positioned
(Fig.8.11b). If the lipoma cannot be satisfactorily
reduced back to this level, removal of the lipoma
should be considered to permit appropriate mesh
positioning.
64
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Fully reduced
cord lipoma
Cord lipoma
Fig. 8.11 (a) A large lipoma is identied running along the cord structures in an indirect defect and (b) the lipoma is
reduced and separated from the cord structures via manual traction
V. V. Alli and E. M. Pauli
Indirect
space
Conrmation ofthe“Critical View”
oftheMPO
Prior to mesh introduction, we review the entire
dissection to ensure the adequacy of the preperitoneal space that has been created, to ensure that
all fat has been reduced from defects, to inspect
for bleeding, and to gauge the size and anticipated anatomical lay of the mesh. Some authors
have described this as assessing the “critical
view” of the myopectineal orice, and we have
adopted this method as a surgical pause in the
case that serves to conrm the dissection is
complete [7].
Mesh Placement
Fig. 8.12 Final positioning of mesh, immediately prior
to placement of mechanical xation
to assist in mesh positioning. We typically avoid
grasping the mesh, as the mesh can be more easA wide array of mesh types are available for
inguinal repair including at and anatomically
shaped sheets. Our personal preference is for
anatomically shaped, reduced-weight polypropylene. The mesh is introduced through the midline umbilical port with using a blunt tipped
grasper holding the medial edge of the mesh. It is
quickly passed through the valve mechanism of
the trocar to prevent loss of pneumoperitoneum
and dragged into the preperitoneal space and
medially. A second blunt-tipped grasper is used
ily shifted using the closed blunt tips of the
instruments than by grasping it.
The mesh should reach the midline (pubic
symphysis) in order to cover all three of the
potential spaces of the MPO (direct, indirect, and
femoral). The inferior edge must be positioned
such that it lays at and is immediately along the
junction of the peritoneum and retroperitoneum
in the inferiormost aspect of the dissection. The
mesh should not have any folds, bends, or ripples
(Fig.8.12).
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